Coding Flashcards
Coding
Description of disease, injures, symptoms and healthcare procedures that are put into numeric and alphanumeric designations
Why do we use codes
Universal codes assist with clinical care, research and education
Reporting for reimbursement
Help with administrative functions
Direct surveillance of epidemic or pandemic outbreaks
Difference between ICD-10-CM and ICD-10-PCS
CM = clinical modification
Used for outpatient
PCS = procedure coding system
Used for inpatient
Benefits of ICD-10-CM for PT
Greater detail Laterality Trauma vs. non Cause of injury Dominant side vs. non Single vs bilateral Type of encounter
ICD 10 code structure
1st = capital letter
2nd = number
3rd = alpha or numeric
All will have at least three
Structure and Format - ICD 10
Alphabetical Index = first step
Tabular list = second for cross reference
ICD 10 - Alphabetical Index
INdex of disease and injury, external causes of injury, tables of neoplasms, drugs, and chemicals
Reference the specific condition, disease, sign or symptom in alphabetical index
ICD 10 - Tabular list
Chapters based on body system or condition
Check for instructional notes regarding exclusions and/or additional characters required for a valid code
Coding for laterality
0 = unspecified 1 = right 2 = left 3 = bilateral Make sure to cross reference though
Injury code doesnt usually have bilateral - then what?
you would code L and R
Placeholder purpose
Allows for future expansion within the code
If a code has less than 6 characters and a 7th is required, then you use placeholders
7th characters are used for
Injuries or other consequences of external causes
Used to describe the type of encounter
7th Character - options
A = initial encounter D = subsequent encounter S = sequela
Excludes 1 Code
Should not report the codes listed when you report the above codes
Excludes 2 codes
These conditions can be on the claim form on the same day you report the above codes
Documentation
Function
Medical Necessity
Support the skills of a qualified therapist
Continued need for therapy
Use physician referral and clinical assessment documentation
Must be specific and relevant to the problem being treated
Medical necessity - interventions should be
Complex enough to require a PT
Provided by or under direction of PT
Amount, frequency and duration must be reasonable and necessary for diagnosis
Intervention plan/goals described in detail and focus upon function
Supported by evidence
Documentation to support services
Patient must show progress or dec risk of further progression of a condition
ICD-10 documentation
Specificity and severity of condition
Other underlying/complicating conditions that may impact prognosis
Support for reported quality data
Support for medical necessity required for coverage in payer policies
Diagnosis must match referring physicians code
4 diagnosis codes per procedure code allowed
PT documentation tips
First listed condition should be primary reason for PT visit
Must be specific
ICD-10 impact on CPT codes
ICD 10 does NOT change any of the CPT codes or HCPCS level II codes used for outpatient
HCPCS level II for durable medical equipment
Medical equipment to assist in function and improved quality of life (wheelchair, walker, shower chair)
Certificate of medical necessity
Approved DME provider
HCPCS level I - CPT codes
HCPCS level I codes is a set of procedure codes based on AMA Current procedural terminology (CPT)
CPT - physical medicine and rehab codes begin with
97001
Some codes are service based and some are time based
Some codes require different level so of supervision
Untimed CPT codes
CPT codes where the procedure is not defined by the timeframe
Only one unit is billed on the same day
Performed by PT or PTA
Eval, Re-eval, Traction, Paraffin
CPT Timed codes
Direct one on one time spent in patient contact
Require constant attendance
Based on 15 min unit of service
Performed by PT or PTA
US, ther ex, neuro re-ed, gait, manual ther, therapeutic activity
8 minute rule for timed CPT codes
Time based units are in 15 minute increments
Time must be greater than 8 min
Total number of units constrained by total time with patient for the day (Medicare)
8 minute rule - impacted by total time - 1 unit =
8-22 min
8 minute rule - impacted by total time - 2 units =
23-37 min
8 minute rule - impacted by total time - 3 units =
38-52 minutes
8 minute rule - impacted by total time - 4 units =
53-67 minutes
8 minute rule - impacted by total time - 5 units =
68-82 minutes
8 minute rule - impacted by total time - 6 units =
83-97 minutes
Delivery of exercise - Therapeutic Procedure
97110
1:1 treatment with PTA/PT
Constant attendance with patient
Timed code
Delivery of exercise - Group therapy
97510
More than 2 patients simultaneously with PT or PTA
Constant attendance with patients but they dont have to be performing the same exercise
What if individual attn while doing group therapy
you can bill with a 59 modifier
Bundled codes
These codes are part of other codes and cannot be billed separately with CMS
Examples of bundled codes
Hot/cold pack
Phonophoresis - can bill US but not separately for meds
Wound care - cant bill separately for bandages
Iontophoresis - cant bill separately for meds
E Stim - cant bill separately for electrodes
Correct coding initiative (CCI edits)
Promote correct coding and ensure appropriate payments
Modifiers - what are they
2 digit codes that tells the payer to pay for something that they usually wouldnt
59 modifier
2 similar procedures performed on same day on same individual
KX modifier
Therapy cap was met but medically necessary for further treatment
GP modifier
Code for PT providing the therapy
Multiple Procedure Payment Reduction (MPPR)
The highest reimbursed code is paid at 100% - the subsequent codes are reduced
Fraud
Intentional misrepresentation or deception
Abuse
No intent to deceive or misrepresent
Examples of abuse
Upcoding Downcoding Unbundling procedures Charging for services not performed Lack of medical necessity
Compliance
Voluntary programs to combat fraud and abuse
Audits
Conducted to be sure billing is accurate
Proposed changes for CPT eval coding structure
3 levels of eval complexity - low, med and high
Right now is fee for service
